Psychology Revision

Schizophrenia
Definition of Schizophrenia
Schizophrenia literally means “split mind” and is the mental disorder
most frequently associated with “madness”.

The male onset is about 4-5 years earlier than the female onset, but
both genders are equally likely to develop the disorder.

The number of cases is lower in some countries than others, and it tends
to be lower in rural communities compared to urban communities,
suggesting that it is related to poverty.

Schizophrenia tends to develop through three stages:

 Prodromal phase (loss of motivation, withdrawal etc)

 Active phase (dominant symptoms appear such as hallucinations)
 Residual phase (gradual improvement in condition, decline in main
symptoms)
Clinical Diagnosis
To be diagnosed with schizophrenia, two or more of the following
symptoms must be present for more than 6 months.

Schnider’s first rank Slater and Roth’s second

symptoms (positive) rank symptoms (negative)

 Delusions  Lack of emotion

 Hallucinations  Inability or
 Disorganised speech unwillingness to
 Disorganised or speak
catatonic behaviour  Lack of motivation
 Inability to display
appropriate emotional
response.
Types of Schizophrenia
Schizophrenia is split into subtypes. However it is often very
difficult for psychiatrists to categorise schizophrenic patients.

Type
Paranoid Schizophrenia
(Most common)
Hebephrenic Schizophrenia
(Disorganised, most associated with being
“crazy”)
Catatonic Schizophrenia
Characteristics/Symptoms
•Usually stable, often paranoid
•Auditory hallucinations
•Believes advertisements etc are
specifically aimed at them
•Agitated, argumentative
•Shallow mood
•Disorganised thoughts
•Incoherent speech
•Hyper and then come to a sudden stupor
•Move around randomly
•Automatically obedient or extremely
resistent
•Withdrawn from reality
•Strange postures
Diagnosing Schizophrenia
Psychiatrists often use diagnostic books or guides to help them
diagnose patients such as the ICD or DSM. These are generally
effective at diagnosing patients as they are updated every couple
of years. However, they are not without their problems.
General advantages and disadvantages:
Advantages Disadvantages
It is standardised between lots of Often culture biased to western capitalist
different people so it is useful in making cultures.
sure everyone knows the correct diagnosis
for each disorder. Is subjective to public opinions and
culture and time, therefore it is less
Change with time so it is current and scientific.
adaptable to what is socially acceptable.
All the books are published at different
Large data bases are used to compile the times, thus making some books more up-
data, it is a rigorous scientific method. to-date than others.

The WHO is not culture bound. IT is The DSM comes from 27 main people so
universally coded. has limited opinions.
Diagnosing Schizophrenia
There are also many issues surrounding the classification and diagnosis of
schizophrenia with reference to reliability (the extent to which psychiatrists can agree
on the same diagnosis) and validity (the extent to which psychiatrists can accurately
predict the development and prognosis)
Validity
Low predictive validity. Bleuer (1978) found that in a sample of 2000 patients, 20%
recovered fully, whilst 40% recovered from positive symptoms and the remaining 40%
continued to have psychotic episodes. This shows that the development of
schizophrenia is more like a lottery as it develops differently for different people.

Some patients go undiagnosed due to social stigmas. Kim and Berrios (2001) found
that in Japan schizophrenia is ‘the disease of the disorganised mind’ and is so
stigmatised that psychiatrists are actually reluctant to tell patients of their condition.
Only 20% of those with schizophrenia are actually aware of it.

There are no pathognomic symptoms, meaning that symptoms are not unique to one
particular disorder. For example, disorganised thoughts could be due to a stress
disorder, flattening of affect could be due to bi-polar and hallucinations are often linked
with drug psychosis. This makes it hard to distinguish between which disorder is
present and makes it even more difficult to determine which type of schizophrenia
patients are suffering from.
Diagnosing Schizophrenia
Reliability
There is very little evidence to support the claim that diagnostic manuals are
routinely used with high reliability.

Whaley (2001) found that inter-rater reliability correlations were as low as 0.11.

Beck et al (1962) found that agreement on diagnosis for 152 patients was only 54%
when assessed by two psychiatrists.

Rosenhan (1973) managed to get 8 healthy people admitted into a mental institute
by claiming to hear single words like “hollow” and “thud”. When he told the hospital to
expect pseudo patients, they accused 41 out of 193 genuine patients of being fakes.

Klostercotter (1994) assessed 489 admissions to psychiatric wards and found that
positive symptoms were more useful for diagnosis than negative ones, concluding that
the symptoms themselves are unreliable.

Subjective symptoms – diagnosis often includes things such as “bizarre behaviour”,

however this is subjective to what people believe to be bizarre.

Copeland et al (1971) gave a discription of a patient to 134 US psychiatrists and 194

British psychiatrists and found that 64% of US psycs diagnosed the patient as
schizophrenic, whilst only 2% of British psycs gave the same diagnosis.
Explanations
The cognitive approach
The cognitive approach
 This approach assumes that schizophrenia is caused by disorganised and
disordered thought processes.
 According to Frith(1979), schizophrenia is the result of a faulty attention
system. Huge quantities of information that would usually be filtered is
not, resulting in an overload. Insignificant information is then considered
to be more important that it actually is. This accounts for the positive
symptoms of schizophrenia, such as disorganised speech and auditory
hallucinations.
 Firth also found that cognitive deficits are caused by abnormalities in the
areas of the brain that use dopamine. He showed that schizophrenics
tended to have less blood flow in these areas when asked to perform
cognitive tasks.
 According to Bentall(1994), there is an attentional bias towards stimuli
associated with danger, such as knives. These receive automatic priority
in processing and may be exaggerated in the process. This sort of bias
causes positive symptoms such as paranoia.
 This idea is shown on how schizophrenics perform on stroop tests. Studies
have shown that schizophrenics take longer to name the colour of ink
when emotional words such as “laugh” or “cry” are printed in the colour.
Evaluations
Advantages
Biology is taken into account.
Studies have shown that
schizophrenics are more
sensitive to emotions than
normal people. This suggests
that there is great processing of
the stimuli.
Disadvantages
Schizophrenics have not been
proven to be any harder to
distract that a normal person
when doing cognitive tasks.
It doesn’t offer an explanation
to negative symptoms.
The idea of an overload in the
brain or extended processing is
impossible to prove.
Lots of people have attention
problems but are not
schizophrenic.
Treatments
Cognitive-behavioural therapy is aimed to
address the sufferer’s dysfunctional
emotions.
CBT aims to help the sufferer challenge
irrational emotions and irrational thoughts,
such as feeling sad for no reason, or
thinking that their family is trying to kill
them.
CBT has been criticised because it is not yet
known whether the irrational thoughts are a
symptom of schizophrenia or the cause.
Evaluation of Treatments
Advantages
Zimmerman et al (2005) found
that CBT was effective in treating
positive symptoms of
schizophrenia.
Often, stressors can cause
relapse in schizophrenics. CBT
can help schizophrenics
recognise that their reaction to
stressors is irrational and
therefore react in a more
appropriate manner.
Is successful when used in
conjunction with drug therapy.
Disadvantages
Turkington et al (1998) found
that CBT was only successful in
treating patients in the short
term.
Zimmerman et al (2005) found
that it is not successful in
treating all subtypes of
schizophrenia
Explanations
The Behavioural Approach
The behavioural approach
 This approach assumes that schizophrenia is caused badly learnt
behaviour through operant conditioning.

 Children may be given sympathy and attention for bizarre behaviour and
so continue the behaviour. They may be punished by being labelled as
“odd” but then take it as a description of themselves and continue to act
odd in order to conform to the label.

 Liberman (1982) suggested that if a child receives little or no social

reinforcement early on in life (neglect), the child will focus on
environmental cues rather than concentrating on stimuli in the normal
way. As a result, the child’s responses will appear bizarre. Those who
observe the child’s behaviour will either respond erratically or avoid it.
This will reinforce the negative behaviour, eventually deteriorating into a
psychotic state.

 Behaviourists explain the fact that schizophrenia rates tend to run higher
in families as a function of social learning. The child copies the behaviour
of the parent until eventually they are given the label “schizophrenic”.
Evaluations
Advantages Disadvantages
Offers hope because you can Doesn’t take into account
relearn behaviour. biology, therefore it is
reductionist.

It can not be generalised to

other cultures. Acceptable learnt
behaviour may be unacceptable
in another country.
It is unlikely that hallucinations
and thought disturbances can be
acquired through reinforcement.
Treatments
Token economy programmes can produce
significant improvements as
schizophrenics begin to show more
desirable behaviour.

Ayllon and Azrin(1968) set up a token

economy inside a psychiatric institution.
They found that the level of socially
desirable behaviour increased as patients
went from performing an average of 5
chores a day to around 40.
Evaluation of Treatments
Advantages
The treatment helps improve
their behaviour in the short term
Offers hope to the patients,
giving them the chance to
relearn behaviour.
Disadvantages
It only works in the short term.
It does not work outside a
controlled setting, therefore
there is a high relapse rate
when schizophrenics leave the
institutions.
The patient’s behaviour could
be superficial because they just
want a reward.
Ethical issues are present
because it isn’t actually
addressing the disorder, it is
just making their behaviour
more acceptable by others.
Explanations
The Psychodynamic Approach
The Psychodynamic approach
 This approach was influenced by Freud and assumes that mental disorders
are due to unconscious processes and fixations in early development
stages.

 This theory assumes that behaviour is a result of processes in “the mind”.

However, it has been criticised by many because “the mind” is only a
theory and can not be proven or disproven. This makes it un-falsifiable
and therefore unscientific.

 The treatment includes psychoanalysis such as “talking therapy”, free

association and hypnotherapy. However, free association and
hypnotherapy have been found ineffective in treating schizophrenia.

 Drake and Sederer(1986) actually found that therapies such as “talk

therapy” often make symptoms much worse.
Explanations
Social Approach
The social approach
 This approach assumes that schizophrenia is caused by family relationships.
 Bateson et al (1956) concluded that parents can cause their children to
become schizophrenic by putting them in no-win situations. EG saying
they’re never affectionate but then saying they’re too old to be cuddled.
This often leaves the child feeling confused about their actions.
 Wayne et al (1977) carried out a study and found that children are more
likely to become schizophrenic when their parents don’t acknowledge what
the child says. This is deviant communication and leaves the child
doubting their words and actions.
 Fromm-Reichmann (1948) found that a high percentage of schizophrenics
viewed their parents as being ineffectual and often felt inadequate.
 A number of studies have shown that most schizophrenics come from high
maintenance families. Linzen et al (1997) concluded that families who react
with high expressed emotion, hostility and intrusion are more likely to cause
schizophrenic characteristics amongst their children.
 Lidz et al researched 14 families who had schizophrenic offspring and found
that in 8 of the families, marital schism was present, in the remaining 6
families, marital skew was present.
Evaluations
Advantages
Sufficient evidence found.
Explains concordance rate
between siblings.
Takes responsibility away from
the sufferer.
This model has lead to the use
of effective treatments.
Disadvantages
Studies can not show cause
and effect as it is unethical to
place people in this situation.
All studies are conducted
retrospectively and therefore
could be biased.
Some schizophrenics come
from ideal families that do not
seem to have any big problems
at all.
Not everyone with family
problems becomes
schizophrenic.
Difficult to obtain evidence as
families don’t always like to be
observed.
Treatments
Family Education – educating families on
how to create a more reassuring home
has been successful in avoiding relapse.

Person-centred therapy – This is where

the patient speaks about their feelings
towards their parents in a non-
judgemental environment. The therapist
offers support and acceptance regardless
of what the patient says.
Evaluation of Treatments
Advantages
Treatments have proven to be
successful in relieving negative
symptoms of schizophrenia and
avoiding relapse.
Disadvantages
Sometimes family education is
unsuccessful in cases where the
family is completely
unsupportive.

Reducing the levels of high

expressed emotions in families
makes other members of the
household less likely to develop
schizophrenia.
 Explanations Biological Approach:
Biochemical/Biomedical/Neuro-chemical/ Dopamine hypothesis,
Neurodevelopmental Approach,
Genetics
The biochemical approach
 This approach has about one million billion kazillion different names. The
main biochemical explanation is the dopamine hypothesis.
 It assumes that schizophrenia is caused by problems with neurotransmitters
that release too much dopamine which causes the positive symptoms of
schizophrenia.
 Post mortem studies have shown high levels of dopamine in the brains of
schizophrenics.
 Amphetamine causes simulation of dopamine and usually cause
schizophrenic-like symptoms. Davis(1974) reported that amphetamine and
cocaine intensifies the schizophrenic symptoms in diagnosed schizophrenics
 Amango (1999) reported that schizophrenics blink more than non-
schizophrenics when staring into space and have poor pupillary reactions to
light, which are clear indicators of neurological disease.
 McNeill(1993) commented that “a considerable body of evidence points to
the existence of structural abnormalities in the brains of schizophrenics”

 However, Davis et al(1991) found that not all schizophrenic patients did
have high levels of dopamine.
The Neurodevelopmental
approach
This model assumes that schizophrenia is caused by badly developed brain structures.

 Post mortems suggest that a disease could have damaged the brain structure in early
development and may have only healed partially.
 Some schizophrenics went through a difficult birth and therefore could have suffered a lack of
oxygen. The reported amount of schizophrenics has decreased over time, indicating that
better maternity care has helped.
 Chua and McKenna (1995) pointed out that the only well-established structural abnormality
in the brains of schizophrenics is lateral ventricular enlargement which is also found in some
non-schizophrenics.
 Min et al (1999) claim that there are substantial shape differences in the thalami of
schizophrenics.

 Torrey et al (1993) believe that schizophrenia may be the result of a virus effecting prenatal
development, causing brain cells to only reach 85% of development.
 O’callaghan et al reported an increased risk of schizophrenia for those in the 5th month of
foetal development during the 1957 influenza pandemic. The virus can then re-activate in
puberty because of the hormone changes.

 Bracha et al(1993) found that if one MZ twin develops schizophrenia, it is more likely to have
hand deformities than the other twin. Suggesting that abnormalities are due to development.
 Stevens (1982) said that “whatever causes the damage only affects those with an inherited
susceptibility to schizophrenia”.
The genetic approach
 This model assumes that schizophrenia is caused by genes.

 There is a sufficient amount of evidence to suggest that the closer the genetic relationship,
the greater the risk of developing schizophrenia.

 Kendler (1985) demonstrated that relatives of those with schizophrenia are 18 times more at
risk than the general population.
 Gottesman(1991) found that schizophrenia is more common in the biological relatives of a
schizophrenic and that the closer the degree of genetic relatedness, the greater the risk.

 Identical twins are 42% more likely to develop schizophrenia whilst non-identical twins only
have a 9% concordance rate. This shows that genetics may play a part but is not the sole
factor in developing schizophrenia.

 Heston (1966) examined 47 children born to schizophrenic mothers who were adopted before
the age of one month. He compared them with a group of 50 children who were born to non-
schizophrenic mothers and reared in their biological families. He found that 5 of the
schizophrenic mothers group developed schizophrenic, whilst none in the other group did.
Evaluations
Advantages Disadvantages
Sufficient evidence found. Post mortem studies are unreliable as the brain
This model has lead to the use of effective structure changes after death.
treatments. It is unclear whether excess dopamine is a
result or cause of schizophrenia.
It is unlikely that dopamine is the sole factor in
schizophrenia as neurotransmitter disorders are
present in other manias but do not display the
same symptoms.
Only successful in explaining type 1 symptoms.
It is hard to establish between environmental
and genetic causes as twins still share the same
environment in the womb, therefore one can not
be sure whether it is a genetic or environmental
cause, eg virus.
Siblings are often reared in the same
environment, making it difficult to conclude
whether it is genetics or outside influences.
Treatments
Anti-psychotic drugs such as
phenothiazines are very successful in
reducing type one symptoms of
schizophrenia. They block/inhibit
dopamine activity.
Evaluation of Treatments
Advantages
Treatments have proven to be
successful in relieving positive
symptoms of schizophrenia.
Drugs are effective long term.
Disadvantages
Sometimes drug treatments
don’t work.
Sometimes the drug treatments
eventually become useless at
treating the disorder.
They only relieve positive
symptoms.
Explanations
Diathesis-stress model
The diathesis approach
 This approach was proposed by Gottesman and Reilly(2003).
 The model suggests that schizophrenia is due to a biological vulnerability
which is then triggered by a psychological/environmental stressor.
 This vulnerability may be due to genetics or the result of illness in early life.

 Tienari (1987) did a longitudinal study into environmental factors by

assessing the quality of parenting. He did this by following a group of
children who had been born to schizophrenic mothers but adopted before
the age of 1 month. He found that all the cases of schizophrenia occurred in
those with “disturbed” families, whilst those whose environments were
rated “healthy” actually seemed to have a lower risk of becoming
schizophrenic than the general population.
Evaluations
Advantages Disadvantages
Sufficient evidence found. Conflicting evidence present.

Takes responsibility away from Studies may be corrupted by

the sufferer. bias.

Is not reductionist.

Longitudinal studies are often

more reliable because they’re
not done in retrospect.